Sunday, November 04, 2007

Friday, the VA said that it believes about 6 percent of returning troops seeking care at its hospitals will be diagnosed with traumatic brain injury, or TBI. From Army Times:

A VA mandatory screening program that took effect in April has looked at 61,285 veterans of the wars. Of those, 19.2 percent were identified on the screening questionnaire as potentially suffering from traumatic brain injuries and were referred for more tests.

While evaluation continues, VA spokeswoman Alison Aikele said officials believe, based on a smaller sample, that the final result about 5.8 percent will be diagnosed with TBI.

Aikele said it is too soon to draw any conclusions from the screening because the program has been under way for only a few months. Until there is more screening and evaluation, VA officials do not want to jump to any sweeping conclusions about brain injuries, she said.

“We did not really know what to expect,” she said when asked if the number of confirmed TBI cases matched VA’s expectations.

However, the 5.8 percent figure appears low. The Defense and Veterans Brain Injury Center, a joint Pentagon-VA research effort, 14 percent to 20 percent of troops in previous conflicts have had traumatic brain injuries. The Center says there are reasons to expect a higher percentage among troops in the current conflicts because improved body armor has made them more likely to survive injuries that would have been fatal in previous wars, and because of the prevalence of roadside bombs and rocket-propelled grenades to attack U.S. forces. The blasts from such weapons can easily cause concussive brain injuries.

In educational interest, article(s) quoted from extensively.

Landstuhl Regional Medical Center, usually the first non-combat zone stop for severely injured troops, initiated its own TBI screening program last year. From Stars and Stripes:

Landstuhl began screening every patient coming in from Iraq and Afghanistan for TBI in May 2006 after doctors noticed that many of them had inexplicable problems that later were diagnosed as TBI.

“We started to say we need to look at people in a systematic fashion,” Flaherty said.

Since then, 23 percent of the 10,000 patients screened for TBI have tested positive. About 98 percent of those have “mild” TBI, which by definition cannot be detected with most brain scanning technology.

Continuing:

Landstuhl Regional Medical Center wants to hire 48 new employees to ramp up treatment of traumatic brain injuries, which affect up to 30 percent of servicemembers returning from Iraq and Afghanistan.

Hospital officials submitted the plan to develop an autonomous brain injury center to Europe Regional Medical Command last week. If approved, plans for the center would require authorization from the Army Surgeon General before moving forward. ...

“We hope to gather data that will allow us to advise on policies that will guide the commanders on the appropriate employment of their troops,” said Army Dr. (Col.) Stephen Flaherty, chief of the hospital’s trauma center. “The units themselves have made changes in how they employ their forces,” though there are no military-wide guidelines. ...

Right now, most doctors prescribe drugs to treat symptoms of the problems associated with TBI, from anxiety to aggressive behavior. However, scientists are trying to develop holistic drug therapies and treatments, “things that would go right for the injury mechanism instead of just treating the symptoms,” Hicks said.

The goal, she said, is to find drugs that can be administered shortly after the injury has been sustained to prevent the cascading effects of TBI from causing further damage. Landstuhl likely would not focus on those kinds of treatments because it receives patients from Iraq and Afghanistan hours, if not days, after they have been injured.

Right now, the hospital’s primary treatment for TBI is “brain rest” — a combination of pain management, limiting exposure to stimuli, and strictly controlling patients’ sleeping and eating habits, said Flaherty.

A decision on Landstuhl's ramped-up TBI care proposal is expected by the end of the year. Meanwhile, closer to home, problems with receiving adequate TBI and PTSD care for some returning veterans is highlighted in a study done for Minnesota's state legislature.

A problem facing returning veterans is that some suffer from TBI or post-traumatic stress disorder (PTSD) or both, and they often do not get proper local treatment, said the study by consultant William Sheenan. He is a Willmar psychiatrist and former head of psychiatry at the Department of Neurosciences at the University of North Dakota in Grand Forks.

Although the federal Veterans Affairs Medical Centers in Minneapolis, St. Cloud, Fargo, N.D., and Sioux Falls, S.D., offer help to veterans with those problems, many vets prefer to get help locally. Others find it difficult to get time to travel to distant VA centers, Sheenan said.

"Our study ... confirmed that local -- and especially rural -- services for veterans returning with mental issues including TBI and PSTD are primitive or non-existent; the most common direction given to those seeking help was to [go to a hospital] emergency room," his report said.

He noted that more than two-thirds of the 21,071 U.S. troops killed or injured in the war resulted from improvised explosive devices that typically caused brain injury as well as other wounds.

"Even mild TBI can increase the risk of incomplete troop readiness and lead to chronic unemployment, substance abuse and suicide," said the 55-page report to the state Department of Veterans Affairs.

Read it in full for first-person accounts and to learn of efforts by Fort Lewis to help its returning soldiers heal, efforts which include a new TBI center at Madigan Army Medical Center:

Army medical officials acknowledge that their service was slow to recognize and respond to the growing numbers of soldiers at risk for mTBI as insurgent bombs struck with greater power and frequency across Iraq.

Research into the “civilian” form of mTBI – generally caused by concussions – shows that most people will fully recover over time with rest and by avoiding additional concussions.

But experts aren’t sure that injuries caused by blasts heal the same way. While much is known about the way the brain reacts to concussions caused by car accidents or sports injuries, researchers are only beginning to examine its response to explosions.

Recent studies suggest that blasts might slowly kill brain cells over months and years, leading to permanent loss of function. Those whose symptoms don’t go away, and the people close to them, have to learn to live with the condition. ...

Dr. Frederick Flynn, a longtime neurologist at Madigan and medical director of the new TBI center, notes that the Army has been dealing with soldiers with TBI for a long time – primarily those who suffer moderate to severe cases.

“Anyone would say in hindsight that we could have done better” in responding to the growing numbers, Flynn said. “But we are screening every single soldier who comes back for this specific problem.”

The new programs are part of the Army “Medical Action Plan,” which arose after media reports of problems at Walter Reed Army Medical Center in Washington, D.C. Combat medics early this year received new guidance for how to assess and treat soldiers who might have concussions. At Fort Lewis, soldiers returning from Iraq and Afghanistan are now required to complete an online questionnaire designed to find those at risk for mTBI.

The 3rd Brigade is the first major unit at Lewis to go through it. Through the end of October, 2,325 of the brigade’s 3,800 soldiers have done so. Of those, 1,000 were found to have likely suffered an mTBI and were recommended for secondary screening at Madigan, which consists of further tests of their cognitive abilities and an appointment to talk with a senior physician or a psychologist.

Of those 1,000, so far 205 soldiers have been referred to further treatment because they continue to suffer signs and symptoms. The figures include some of the 204 soldiers who were diagnosed with mTBIs while the brigade was in Iraq, brigade officials said. Flynn said all 3,800 soldiers in the brigade will be screened again in three to six months.

Finally, historical review of TBI appears in this month's American Journal of Psychiatry. Details:

Professor Edgar Jones, Dr Nicola Fear and Professor Simon Wessely's historical review ‘Shell Shock and Mild Traumatic Brain Injury – A Review’ has been published in the November issue of the American Journal of Psychiatry.

Working at the King's Centre for Military Health Research, Jones et al have written this review looking at the nature of shell shock, its clinical presentation, the military context, hypotheses of causation and issues of management and consider whether there are contemporary relevancies to the current signature injury of the Iraq and Afghanistan conflicts, known as Mild Traumatic Brain Injury (MTBI).

Professor Jones explains: "Mild traumatic brain injury is not a new disorder confined to Iraq and Afghanistan. Its symptoms and military context bear strong similarities with shell shock in World War One and post-concussional syndrome in World War Two. There are dangers not only in assuming that MTBI is novel but in characterizing it solely as an organic injury. The evidence of the last two World Wars is that brain injury often arises in a context of psychological distress, requiring us to consider the physical but also the mental health of those with concussive injuries."

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